Medical Staff

Featured column: Tips for using outside peer reviewers

Medical Staff Leader Insider, April 29, 2009

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Medical staff leaders are often daunted at the prospect of engaging and paying outside peer reviewers. This article contains a few tips on when an outside reviewer is necessary, how to select the right reviewer, and how to ensure that your facility puts a reviewer’s feedback to good use.

Pursuing an outside reviewer: External peer review plays an important role in ongoing professional practice evaluation (OPPE), which must include input from a peer who practices in the same or similar discipline as the medical staff member under review. Some experts take the position that, for example, a hand surgeon must evaluate a hand surgeon, and a CRNA must evaluate a CRNA. When a hospital has only one specialist on staff qualified to evaluate another’s performance, or when the specialist practices in the same group as the medical staff member under review, this requirement can be difficult to meet.

Even more difficult is focused professional practice evaluation (FPPE), which hospitals are required to perform to verify the competence of physicians who are new to the medical staff, existing medical staff members requesting new privileges, and physicians whose performance raises concerns. In instances when a practitioner’s performance is in question, an outside reviewer’s comments are extremely valuable. He or she is free from any conflict of interest that may affect a partner’s or competitor’s judgment during a review. This enhances medical staff members’ confidence in the peer review system and is especially helpful during a fair hearing or lawsuit. The outside reviewer can also add new insights about how the system or culture contributed to an incident, because he or she is not steeped in the history of “how we’ve always done things.” 

Selecting an outside reviewer: The outside reviewer should be a skilled physician with a solid reputation, but the cost of hiring an outside reviewer, particularly for OPPE, can be a challenge for some hospitals. Some hospitals have identified a network of other similar facilities with which they exchange external review services. Other facilities have found that nearby academic medical centers or outside review firms are willing to work with them to reach a cost-effective arrangement for routine reviews.

The reviewer’s qualifications are even more critical in the case of FPPE, because the results of FPPE could lead to corrective action. Therefore, hospitals must carefully vet outside reviewers. It may be wise to contract with an organization that specializes in offering review services or an academic medical center with an excellent reputation. The reviewer should be free of any conflict or bias.

Getting the most out of reviewers’ feedback: Be sure that your policy or your process affords reviewers legal protection and that their comments will be treated as privileged, if possible. This might be accomplished by appointing the reviewer as an advisor to the medical staff. However, check with your counsel to be sure that you make the proper arrangements under your state’s laws. Once you have entered into an appropriate arrangement, be sure to provide the reviewer with important information, such as which services are not offered on the weekend or protocols for certain types of cases. 

With this information, especially in the case of FPPE, the reviewer will be better prepared to answer specific questions to assist with the medical staff’s decision-making. For example, the reviewer might address whether a surgeon performed appropriate case selection in light of reduced hospital capacity, or whether he or she used good judgment during a procedure. Counsel can help frame these questions, as they may be central to a later fair hearing. The reviewer can also rate a physician’s overall care or judgment, but these specific questions help to ensure that the medical staff receives information it needs. 

Theresa Rambosek is an attorney with healthcare law firm Bennett, Bigelow, & Leedom, P.S. based in Seattle. She can be reached at

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